Sunday, May 15, 2011

The Doctor will See You Now

Although I often hear people lamenting the side-effects and potential pitfalls of medications for conditions such as ADD, I for one find them to be a godsend. In my case, the medication is Adderall.

My mind seems to have two speeds: on and off. When on, it's like a wood chipper on mission searching high and low for something to consume and process, never resting until it's found more input than it can process, enough to slow it down a bit. In the absence of sufficient ambient stimulation, I tend to manufacture it searching for problems to be solved, provoking debate, transforming ceiling tiles into puzzles.

For me, large meetings, lectures and classrooms are torture. Three lines into a presentation, I'm pretty sure I understand where it's going and what the conclusions are; attending to the remainder of the presentation is like watching a poorly produced thriller where someone told you the ending during the opening credits and you really need to pee.

Fortunately, I've got what people refer to as a "creative" mind. Left on my on my ADD isn't an issue; it's never a challenge to adequately supply it. However, when working with others, well, Adderall is a godsend.

Last week, I attended the International Meeting for Autism Research (IMFAR) in San Diego. For me, conferences with lots of academics and PhDs are the core reason god created Adderall. The problem is that my prescription for Adderall ran out in the middle of the conference. Why is that a problem? Why not just get a refill early? Why not plan ahead?

Adderall is what is referred to as a Schedule-II controlled substance, an amphetamine that must be prescribed by a doctor, filled by a pharmacist, and delivered only to the person to whom it is prescribed. The prescription cannot be called in to the pharmacy and it cannot be filled earlier than required. Instead, you arrange for your doctor's office to mail it to where you're going to be at the time you need it refilled.

We did that.

So, on one particularly wood-hungry morning, I mention to Iris that I'm off to the local CVS to get my prescription filled. I walk to where Google-maps says the CVS should be, but there is none. I close my eyes and visualize a second location. It's there. I walk back to the pharmacy desk, pull out my driver's license and prescription, and hand them to the attendant.

She looks down at the prescription, up at me, down at the prescription, up at me and then says, "I'm sorry, this prescription is not written on the right kind of paper."

She hands it back to me, turns and walks away.

I call out, "Wait, what do mean it's not written on write kind of paper?"

She turns back, "In California, a prescription must be written on blue prescription paper like this. It's the law."

She turns again.

"Wait, then how am I supposed to get this prescription filled?"

She turns. "You can't." She turns.

"But, there must be something I can do?"

Turns. "You could get a doctor here to transcribe it." Turns.

"Do you know a doctor?"

I head down Market Street looking for Gas Light Medical. The sign on the door reads no appointments necessary. The receptionist finally concludes her conversation about her previous evening and turns to me asking how she can help me. I explain. She hands me forms and tells me the visit will cost $120. I complete the forms, pay her and take a seat in the waiting room.

Ninety minutes later, a young man in hospital blues sticks his head out the locked door leading to the exam rooms and calls my name in a beautiful Jamaican accent. As I enter the examination area, I pass an armed security guard whose name tag reads "Dolores". Her grim demeanor melts, she smiles, says, "Hey, Honey" and winks at me.

The nurse straps on a blood pressure sleeve, places a pulse sensor on my index finger, thrusts a thermometer under my tongue and instructs me to relax. After five attempts in which the measurements read,'Error', he scribbles something on a pad and tells me that the doctor will be in momentarily.

I wait. In the background, I hear the receptionist screaming at a speaker phone complaining to someone that the fish tank is a disaster and that the called party needs to "get out here and fix it."

Thirty minutes later, no doctor. I get up, throw my backpack over my shoulder and head out the door. There's a commotion behind me and then someone calls out, "Sir, please, the doctor will see you now."

The doctor emerges from his office, still chewing on his sandwich. I explain the situation. It takes him twenty seconds to complete the task. I hear Dolores call out, "You come see us again!" as head out to the street and back up to the CVS.

The attendant says, "That will be four to five minutes, sir. Would you like to wait."

"Sure."

I take a seat and notice the other man behind the glass don his jacket and head out the door.

Half an hour later, I walk up to the attendant and ask here how much longer she expects it to be. She looks at the clock and says, "Sir, I said it would four to five minutes."

I say, "Yeah, that was half an hour ago."

She says, "Yes."

I say, "But I thought you said it would be four-to-five minutes."

"I did."

"And that was half an hour ago."

"Yes. It's not yet been four t'five minutes."

Click.

"I see. Well, is it possible that you could just fill the prescription now?"

"No, I don't have the key. Only the pharmacist can fill the prescription."

"You mean the guy who got up and left a few minutes after I returned?"

"Yes."

"Well, umm, seeing as you knew why I was here and that I'd already spent two-and-a-half hours trying to get my prescription filled, do you think you might have asked him to fill it before he left?"

"I guess so."

She turns.

Half an hour later I walk into the Grand Hyatt and up to the conference with an amazing sense of frustration.

This morning I've been contemplating how to persist like the proverbial dog-with-a-bone without becoming attached to the outcome.

Any ideas?

Happy Sunday,
Teflon

14 comments:

  1. Ideas:

    1: Don't go to California without aderall
    2: Always ask questions such as "Are there anything I do if I want my perscription as fast as posible
    3: Always check if you have understood what was said, such as: 4-5 min does that mean he'll be back before xx hrs
    4: find out how train your brain / body so you do not need adderall

    I got somewhat annoyed yesterday when I didnt verify: when you say you'll take a cup of coffee at 6 and then go to my place, does that mean that you'll be here 9'ish or...?

    Love Joy


    This is one reason why I use my persistance to find ways to change my adhd.

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  2. 5. Don't attend IMFAR without boning up on the Jamaican accent first :-(.

    I think anybody would have flunked that test, Tef; ADD or not.
    sree

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  3. Sree, Frack,
    Thank you for the insights. I appreciate the stimuli avoidance tactics and I'm usually quite good at employing them, so good in fact that I often miss opportunities to engage the stimuli zero in on my frustration buttons.

    What I'm how to manage those stimuli in a manner that doesn't frustrate or annoy. What's the jujitsu of it. There's avoidance (i.e., don't get there in the first place). There's denial (e.g., red-facedly say, 'I'm not annoyed'). There's surrender (e.g., call it a day and determine try again tomorrow). And then there's something that I'm sure one can do to turn the tables on the frustration in the moment, let go of the attachment and then engage with increased vigor.

    It's the last of those I'd like to figure out.

    Teflon

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  4. Tef, have you ever "turned the tables on frustration in the moment" before? Maybe those times contain a clue...

    Faith

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  5. Faith,
    That's a great question. Nominally, it's not a problem. I just see that I'm doing it and decide not to. It's usually some form of context-shift. The frustration doesn't come from the stimulus, but from the context I've created around the stimulus, i.e., my beliefs and my awareness.

    Even while sitting in the doctor's office, I could see all this. I would ask myself, "Even if this takes another couple of hours, what's the big deal?"

    And yet, I didn't want to let go of the frustration. In the moment, getting my prescription filled and getting back to the conference took a back seat to something else. I think the something else was trying to figure out a way to break through the indifference of others or something on that order. You know, today I'm gonna buy groceries, go for a run, drop the kids at school and, oh yeah, break through indifference.

    In the moment, I believed that the loss of frustration would cause me to ignore the indifference and that would have been a "bad" thing.

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  6. I understand that there is a belief that indifference is a bad thing - and for some reason it would be even more bad if you did not fix it -and help these people to change behavior.

    But couldnt there be another part to the frustratione the "am I doing the right thing by staying" - right meaning doing what is most optimal for myself?

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  7. Joy, I think there could be that part. However, it's probably at that level that we each start to follow our individual idiosyncrasies.

    I like where you're going with digging down a level.

    As I ponder what would lie one level beneath, it occurs to me that I was frustrated with my inability to communicate and motivate. I SHOULD be able to get these people to see that it would be a better world if we each were more engaged and less indifferent--a better world for them and for me. And yet, I was completely ineffective.

    I cringe (I know, judgment) at the thought of it, but perhaps I was using my frustration as a motivator for others. Lord know it gets used enough for that.

    So here's what for me is the interesting next question. On the one hand, I don't like the idea of using frustration, agitation and anger to motivate others. On the other hand, it's a proven method. Similarly, I don't like the idea of ever being perceived as sympathetic (we can go into that sometime), but being sympathetic (or appearing pathetic) works.

    Do you guys have any contradictions like that working for you?

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  8. Tef: the question of whether to use the time-tested unhappy methods to motivate others comes up often, and I make my choice based on whether I want the immediate outcome (getting what I want) more than the long-term outcome (reinforcing those methods in the world). But that's only when I'm aware (in the moment) that I'm using unhappiness.

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  9. Sree,
    I understand the notion of trade-offs made between short-term and long-term results, but it occurs to that the stated trade-off is in almost all cases fallacy.

    It assumes an equal weighting factor. However, except in rare instances, the long-term impact of short-term decisions is negligible. Were it not, we wouldn't have so many stories highlighting the unanticipated long-term consequences of near-term decisions; the stories wouldn't be interesting unless they highlighted the exception to the rule. (BTW, in case it weren't obvious, I'm leaving out the impact of repeated short-term decisions.)

    Statistically speaking, a short-term decision has zero-impact on the long term.

    So then, why do we often find ourselves doing things based upon the assumed trade-off? Perhaps it's simply that we don't recognize the fallacy? Perhaps it's because we buy into slippery-slope? Perhaps we do it for the principle of it? Perhaps it the fruitless pursuit of perfection?

    I've probably been using a combination of all the above. Until now. And then for some reason, your comment got me thinking in a way that broke through all that.

    Pretty cool.

    Thank you!
    Teflon

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  10. Tef: you'll have to walk me through this, because I must be missing something big.

    You say "except in rare instances, the long-term impact of short-term decisions is negligible". You then proceed to say more about decisions in general, and then say "I'm leaving out the impact of repeated short-term decisions".

    I'm completely stumped. The way I was looking at it, the long term is made up of a number of short terms. Decisions we repeat over enough short terms tend to shape our long term. So the greater the number of such decisions and/or terms, the smaller the impact of each decision in the long term. But to equate "negligible" to "zero", and thus dismiss the tradeoff, seems to be over-simplifying the matter.

    I've often considered this tradeoff in the matter of recycling. When I walk over to drop my used newspaper in the recycle bin, instead of the more conveniently placed trash can, it has a negligible effect on the environment. After all, billions of people probably trashed their newspaper today. What difference will one newspaper make? Am I going to get a Nobel Prize for this great achievement?

    If that were to be the only time I'm faced with this choice, then sure, we could say its impact is zero, and I could I go either way with the paper. I see all three considerations working here (slippery slope, principle and pursuit of perfection), and I can see how they are eliminated by the absence of the impact.

    But then one consideration occurs to me. Let's say my impressionable 8-yr-old son (or my neighbor, or a passing driver) chose today to observe my waste-disposal habits and decided to adopt them for himself. That right there doubled (at least, probably more) the impact. Sure, it may be unanticipated, but perfectly reasonable; it's my omission for not anticipating it.

    If anything, the fallacy may well be equating "negligible" to "zero". High-school math is a distant memory; however, isn't calculus based on infinitesimal changes of one variable due to changes in another? I remember doing "1/x approaches zero as x approaches infinity", but as long as x is finite, 1/x is not zero. I might even say that since I won't live for ever, each of my decisions is bound to have some non-zero impact.

    However, continuing to consider a decision in isolation, with no regard to the number of times it may need to be made, if we grant that it has actually zero impact long-term, then what (in your example of waiting for Adderall)? What would change?

    Also, I don't think I was assuming an equal weighting factor. In fact there's no factor; there are two quantities, with the question being which is greater. I think the short-term benefit of employing unhappiness (getting one's way) almost always wins, which is why 'it works'.

    I can't wait to discover what I'm missing here. In fact, the suspense is killing me.

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  11. Sree,
    Thank's for your response. This is fun.

    There are a couple of challenges with your arguments. The first is the assumption that a single action will be repeated. I believe that the likelihood of any single action causing long-term impact in the absence of repetition is negligible. You may argue that the probability of repeating an action is high, but that wouldn't negate my belief regarding non-repetitive action.

    One might go so far as to say that your concern about repetition implies tacit agreement with my original statement, but that you find my statement irrelevant because the likelihood of repeating an action is so high.

    So the question becomes one of the likelihood of long-term repetition of short-term actions. This is where I think many of us abandon thought for philosophy or principle. We often assume that short-term actions will be repeated over the long term without questioning it. It's right up there with assuming that in order to be successful, one must go to college.

    While there are many examples of long-term repetition of short-term actions, there are also examples of things we do only occasionally or once. There are people who smoke cigarettes daily, people who smoke only occasionally and people who try it just once. Some people go on vacation and then decide to change their lives, leaving their jobs and locations to move to the vacation spot. However, most of us don't. The possibility that our short term vacation may become a long-term thing doesn't stop us from vacationing.

    So, the question of something repeating over the long-term is simply a decision. Yet, many times we're almost superstitious about it; better not try it lest I continue doing it. If I do it, what's to stop everyone from doing it. And so on. Sure, the possibility exists, but the question is one of probability.

    Calculus presumes a formula or pattern in order to work. Without the pattern, without consistent repetition, calculus doesn't work. For that matter, you needn't go any further than geometry to see that two lines diverging even by the tiniest angle end up infinitely apart. However, if requires the divergence to continue infinitely.

    Statistically, negligible is zero. I think you're questioning whether or not the impact would indeed be negligible, not whether or not negligible equals zero. Perhaps you're arguing that the impact would be significant.

    I'm not suggesting that one consider everything in isolation. One would fare well to be aware of patterns. I'm suggesting that one not assume a pattern will emerge. In fact, I would suggest that the assumption that a short-term action will have long term consequences is one of the top reasons people give up on things like exercise plans, diets, learning new skills, etc. A deviation from the plan is so overloaded with meaning that people assume they're going to fail "anyway".

    Sure, there is the case where someone observes your onetime action and it dramatically impacts them. However, the likelihood is low and the impact unpredictable. The kid who sees you toss the trash may be inspired to emulate you or to never become like you.

    So, I guess we agree regarding isolated action that is never repeated? However, the question is one of probability versus possibility, and which way your assumptions tend.

    Sorry for the run-on.

    What do you think?

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  12. Thanks for the elaborations, Tef; sorry it took me so long to respond. Can’t say it cleared everything up – there were still a couple places where I went ‘huh?!’ – so let me see if I can make any more sense of it.
    - first off, I caught my calculus/geometry diverging-line error myself right after I hit ‘Post Comment’.
    - yes, I kept thinking of repetitive actions more than isolated actions.
    - I agree with your caution about patterns – both to recognize them when they exist, and to remember they aren’t inevitable. We would all do well to recognize that it is we who decide whether to repeat or not repeat a past action.
    - Your statement “the likelihood of any single action causing long-term impact in the absence of repetition is negligible” sounds rather sweeping to me. Either you are ignoring/discounting the handful of big decisions everybody makes in their lives (choice of occupation, hometown, spouse, residence, etc), or you’re thinking of only *irreversible*impact.
    - I have a couple more nits to pick (“ likelihood of someone observing the one-time action is low”, possibility vs probability, etc)but …
    - To crystallize & focus our discussion, maybe we could go back to the original situation – trying to get your medication faster without resorting to anger or frustration – and ask how the foregoing discussion applies there. Isolated vs repetitive action, negligible or significant impact, etc? How would your decision change now that you’ve recognized the fallacies in operation? What considerations could we use if a given action/decision like this one has no long-term impact?

    I’m trying not to split hairs or to stretch this out unnecessarily, but I’m really keen to identify any errors in my thinking, since making good-quality decisions is critical to just about everything in life. I know just writing these comments have forced me to crystallize my thoughts in a way I never did before.

    sree

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  13. Sree,
    I think we may be getting hung up on the words "likelihood" and "negligible", mostly on "negligible".

    Let's start with likelihood. By likelihood, I mean nothing other than frequency, e.g., 1 in 10, 1 in 100, 1 in 1,000, 1 in 1,000,000. What is the frequency in which an isolated action has significant, longterm impact?

    I think you would agree that isolated actions only infrequently have significant longterm impact. The frequency is reduced when we consider that the fact that the point at which we identify a decision is "never", (i.e., zero-percent of the time) an isolated action; it is "always" (i.e., one hundred percent of the time) the result of a sequence of actions and decisions. (I use zero and one-hundred flagrantly simply because Jonathan always lectures me that to use either zero or one-hundred percent as probabilities is oxymoronic.)

    So, since the likelihood is minimal (for the moment, let's assume that it is), the question would be about "negligible". I think that negligible is the more loaded word because it often means "doesn't matter" or "don't care".

    For each of us there are events and actions that no matter how unlikely would be meaningful. I think that this gets to the heart of how many of us make decisions; we lump together likelihood and significance. For sure, there are cases where the likelihood is extremely low, but the impact extremely high, e.g., major airline crashes, nuclear meltdowns, lighting striking the same human twice in the same place, capable politicians. However, because the impact is so extreme, we often drop likelihood as a criterion. Good decisions take into account both likelihood and potential impact (weighting).

    Regarding so-called life decisions, I would say that we often make "bad" ones simply because we overload them with significance, specially the ones that are correctable or reversible. Most decisions can't be made well until after they've been made and most decisions can be corrected or reversed. (Whether or not they can, it's probably a useful belief to adopt. It would save a lot of handwringing)

    OK, back to the prescription. I think I'll stick with using frustration as a way to get what I want. For whatever reasons, expression frustration resulted in both the doctor and the pharmacist changing their behaviors in a manner consistent with my goals.

    However, in hind sight, I'd only have used the affect of frustration without feeling frustrated. It's kind of like switching languages to be better understood in a new culture. If the culture is one that speaks using frustration and anger, then you'll need to speak with frustration and anger to be heard. (Well it's not exactly like that, but there's something to speaking the language.)

    Using the affect of frustration right away would have saved me an hour and if I'd gone to it earlier, I would have reduced the likelihood of feeling frustrated. Further, the people to whom I expressed my frustration seemed not at all flustered by it. It was almost as though there was a cultural mandate: don't do anything until the customer becomes frustrated. Had I not got frustrated, we might have ended in a stale mate.

    I'm not sure if that's any clearer, but I"m learning a lot through our dialog.

    Tef

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  14. Tef: I'm completely with you on the issue of likelihood & impact, and how they both need to be considered. In fact, the newly popular science of Risk Management assigns scores to each to quantify Risk.

    However, I must confess I'm still confused by your reliance on probability. If we're sitting at this point in time and formulating strategies for all decisions in the future, probability would come into play. But when we're at a particular situation and needing to make a decision, I wouldn't have thought we'd use probability anymore. (In fact, there was more than one point where I really thought you were kidding). Anyway, I won't belabor the point but will test out everything we've discussed here. Thanks for the great exercise!

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